Source · Prevention of Future Deaths

Prevention of Future Deaths Reports

Browse 6,383 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.

Response tracker Organisations Advanced search

Keyword

Browse by year

Browse by region

Sort

Reports

6,383 reports · Page 228 of 320

Date	Report	Region / area	Addressee(s)	Responses identified
24 Jul 2017	Patricia Parker 2017-0454 · Thomas Osborne Numerous sedation guidelines are not widely known by clinicians, highlighting a need for better training and awareness of sedation risks, especially in …	South East Milton Keynes	NHS England	0/1
24 Jul 2017	Khuong Lam 2017-0455 · Christopher Woolley Mental health guidance lacks provisions for reviewing Section 17 leave upon ward transfer, and there's a need for better communication to clinicians …	Wales South Wales Central	Chief Medical Officer for Wales	0/1
7 Jul 2017	Catherine Roberts 2017-0076 · Nicola Jones Problems with admission to the Emergency Department, resource availability, and patient flow continue despite previous reports to the Health Board, placing patients' …	Wales North Wales (East and Central)	Betsi Cadwaladr University Health Board	0/1
22 Jul 2017	Linda Baranowski 2017-0341 · Geoffrey Sullivan Widely available diet supplements and a hot slimming cream contributed to a fatal inflammatory response, raising concerns about the sale of products …	East of England Hertfordshire	Hertfordshire Trading Standards National Food Crime Unit, Food …	2/2
21 Jul 2017	Pauline Taylor 2017-0330 · Mary Burke Emollient creams with paraffin pose an unrecognised fire hazard due to inadequate warnings and lack of awareness, alongside insufficient patient risk assessments.	Yorkshire and the Humber West Yorkshire (West)	Arjo Huntliegh Care Quality Commission Department of Health and Social … Locala	5/9
8 Aug 2018	Deidre Harvey 2018-0266 · Christopher Woolley External consultants had insufficient input into mental health patients' physical care, bureaucratic processes delayed rectifying ligature points, and the system for managing …	Wales South Wales Central	British Association of Dermatologists British National Formulary Cwm Taf Morgannwg University Health … Department of Health and Social …	5/7
19 Jul 2017	Edith Robinson 2017-0452 · Lisa Hashmi Lack of weekend consultant review, inaccurate early warning score calculation, and consistently poor record-keeping by staff compromise patient safety, risking delayed diagnosis …	North West Manchester (North)	Department for Health	1/1
18 Jul 2017	Ivy Mitchell 2017-0453 · Alison Mutch Inaccurate falls risk documentation, poor staff understanding of risk assessments and post-fall procedures, and non-compliance with escalation processes jeopardised patient safety.	North West Manchester (South)	Fairfield View Care Centre Tameside Borough Council	1/2
17 Jul 2017	Matthew Edwards 2017-0451 · Alison Mutch Hospital discharge processes were severely deficient, with long delays in dispatching summaries to GPs, failure to book follow-up appointments, and significant waits …	North West Manchester (South)	Tameside and Glossop Integrated Care …	1/1
14 Jul 2017	Sabrina Walsh 2017-0449 · James Healy-Pratt The absence of CCTV in corridors and communal areas at the acute care facility delayed locating vulnerable patients, risking timely intervention.	South East East Sussex	Department of Health and Social … Sussex Partnership NHS Trust	2/2
14 Jul 2017	Steffan Bonnot 2017-0450 · Penelope Schofield Inadequate and undocumented disclosure of a child's background information to prospective foster carers caused anxiety and posed a risk to informed placement …	South East West Sussex	Ofsted	0/1
12 Jul 2017	Elaine Davison 2017-0444 · David Hinchliff A diseased tree, despite prior examination, had a hidden severe fungal decay that was missed due to inadequate inspection and misidentification of …	Yorkshire and the Humber West Yorkshire (East)	National Tree Safety Group	0/1
12 Jul 2017	John Wilson 2017-0445 · Andrew Bridgman The product recall process was inadequate, relying on unrecorded standard mail that failed to inform the deceased, and lacked further robust efforts …	North West Manchester (South)	Beko Plc	0/1
11 Jul 2017	Doreen Willis 2017-0439 · Ian Arrow Concerns relate to key learning points from a Root Cause Analysis report on care homes, urging the CQC to review its inspection …	South West Plymouth Torbay and South Devon	Care Quality Commission	1/1
11 Jul 2017	Margery Astill 2017-0440 · Lydia Brown Ineffective diary systems led to failures in referrals, the system for updating incident reports was unclear, communication with family members was inadequate, …	East Midlands Leicester (City & South)	Leicestershire NHS Trust	0/1
11 Jul 2017	Hannah Barney 2017-0442 · Andrew Harris A regional trauma centre lacked a 24-hour consultant plastics surgical service, risking patient lives due to potential delays in urgent debridement for …	London London Inner (South)	Department of Health King's College Hospital NHS Foundation … NHS England	0/3
7 Jul 2017	Sousse (Tunisia) 2017-0206 · HHJ Loraine-Smith Travel companies lacked board-level security advisors and failed to prominently display government travel advice, leaving customers potentially uninformed about terrorism risks in …	London London (West)	ABTA Civil Aviation Authority Department for Transport Foreign, Commonwealth & Development Office	0/4
8 May 2017	Andrew Wilson 2017-0152 · Alan Blunsdon No arrangements existed to provide peritoneal dialysis at non-renal hospitals, and treating clinicians were unaware of this service gap or the unavailability …	South East North East Kent	East Kent Hospital Foundation Trust	0/1
8 May 2017	David Sheppard 2017-0153 · Louise Hunt Communication breakdowns due to poor English language skills among care staff, inadequate first aid training, poor record-keeping, and substandard post-event investigation hindered …	West Midlands Birmingham and Solihull	Boldmere Court Care Home Care Quality Commission Department of Health and Social …	1/3
10 May 2017	Richard Bull 2017-0154 · Sean Cummings There is insufficient public perception of the risk associated with phone chargers in contact with water, requiring urgent and prominent safety warnings.	London London (West)	Apple	0/1